Getting private doctors to submit info for national database laudable, but challenging

Health Minister Gan Kim Yong announced last week that the government would compel all healthcare providers to contribute to the National Electronic Health Record (NEHR).

Despite some cries of concern from the medical community, this is way overdue and the right thing for Singaporeans.

The government had in fact rolled out NEHR six years ago, but due to the poor take-up rate among doctors in private practice resulting in huge gaps in records, the authorities will now table legislation next year to make it compulsory.

In this era of “multiple medical conditions” punctuated by outbreaks of infectious diseases like SARS and dengue, the Ministry of Health (MOH) correctly recognises that healthcare can no longer be only a cosy, one-to-one relationship between doctor and patient.

The doctor-patient relationship is of course still sacrosanct and the foundation of care, but medicine and public health are also team endeavours requiring multi-disciplinary skills, including behavioural coaching and sophisticated information technology management.

Imagine a future where your family doctor, at the touch of a button, can call up colourful visualisations of all your past consultations including hospitalisations, medicines and laboratory results.

In this same future, your doctor is prompted that it is time for your mammogram and Pap smear. She also reassures you that the medicine prescribed for your fever will not interact adversely with the ones prescribed by your endocrinologist.

Sitting in an office 10 kilometres away, a MOH official is alerted that you and 10 of your neighbours have similar diagnoses of ‘viral fever’.

There are also increased sales of paracetamol in the neighbourhood, a spike in online searches for ‘fever’ and ‘muscle aches’ and a National Environment Agency report of stagnant water in your community testing positive for the Aedes mosquito larvae.

As you get up to leave, your doctor suggests a blood test to check for dengue and chikungunya “just in case”.

Far-fetched? Not at all. These technological capabilities already exist today and as Mr Gan notes, “patients can only realise the full potential of the NEHR if the data is comprehensive”.

This is a voyage worth undertaking and a journey everyone has to take together.

OVERCOMING CHALLENGES

Nonetheless, the journey to this future is fraught with immense operational challenges. The current version is reported to be less than ideal but as with many IT initiatives, early versions will be clumsy and should not be a reason to reject NEHR. We must be confident later iterations will deliver on the promise of NEHR.

What needs to happen?

Data input into NEHR must be straightforward and so fast that the time impact on a busy practice barely discernible. Consideration should be given to auto-population with associated lab and prescription information ‘pulled’ from other health IT systems.

The contributing doctor then simply enters the diagnosis and reviews the rest quickly.

When using NEHR, doctors cannot be overloaded with a morass of data poorly organised and having to spend precious time going through file after file to find the information needed.

Instead the interface must be so cleverly designed and intuitive that in one screen, doctors would have all the information they need for the vast majority of patients.

Twenty years ago, Richie Williams, a young boy in England died following injection of a chemotherapy drug into his spine instead of his vein.

Following investigations, the two junior doctors responsible were cleared of manslaughter when the prosecutors decided death was caused by a catalogue of “chance events and failings” at the hospital, rather than gross negligence on the part of the two.

Similarly, we cannot blame doctors if NEHR is poorly designed and results in errors and omissions by doctors.

Beyond poorly organised information, what happens if the patient data is simply wrong? Doctors use the clinical data in NEHR to make decisions and being misled by false information can harm patients.

For example, a doctor prescribing a second choice antibiotic because of an allergy to the first choice wrongly documented in NEHR cannot be faulted for a poor patient outcome.

Instead blame should be borne by the careless first doctor, with some apportion to NEHR. One might argue NEHR is simply a platform, but platform owners should have responsibilities too.

If we hold the position that platforms like Google and Facebook “bear significant responsibility” in tackling inappropriate content, as Home Affairs and Law Minister K Shanmugam alluded to earlier this year in a conference on fake news, then why should not NEHR have some responsibility if falsehoods are disseminated through its system harming patients in the process?

What mechanisms should NEHR have to vet the accuracy of the information submitted?

Finally, the privacy concerns raised by many including the Singapore Medical Association are very real.

MOH must recognise these and reassure medical practitioners and their patients. Nonetheless, I do not agree that some parts of the medical history should be excluded from NEHR given the public health value of a comprehensive NEHR.

The concerns centre particularly on ‘sensitive’ conditions such as HIV and sexually transmitted infections. But many of these are legally notifiable diseases and the MOH would already have the information.

The authorities have said that sensitive health information, such as sexually transmitted infections and mental health conditions, can be accessed by health practitioners only if it is relevant to the service they are providing to the patient. This is not good enough.

What in my view would still be essential though is a sensible system of layered access and proactive mechanisms to disallow viewing information unnecessary to routine clinical care.

This is not trivial from a design perspective as most medical conditions can be identified by knowing what medicines a patient is on. Allowing access to the list of medicines a patient is on is effectively revealing medical conditions.

Likewise for allergies: documentation of allergy to rifampicin or azidothymidine would lead a doctor to suspect prior treatment for tuberculosis or HIV respectively.

By mandating contributions to NEHR, MOH is becoming the custodian of Singaporeans’ health information and by default, assumes accountability for this crucial role.

Any privacy breaches - malign or otherwise - cannot be blamed solely on errant doctors and MOH as system designer and steward has to bear equal if not more responsibility.

There is no point apologising to the Singaporean whose life is ruined because of public release of confidential health information. Punishing the offending healthcare professional permits some modicum of justice but scant solace for the affected patient.

NEHR is a critical enabler to bring our health system into the future and ready Singapore for the different care models an aging population with multiple medical conditions needs.

In the drive to ensure NEHR is comprehensive, Minister Gan and the MOH are taking an immense responsibility upon themselves. This is wholly admirable and we as healthcare professionals and fellow Singaporeans should play our part to support them.

ABOUT THE AUTHOR:

Dr Jeremy Lim is head of the Health and Life Sciences Practice in Asia at Oliver Wyman, the global consultancy.